Basic Information
| Provider Information | |||||||||
| NPI: | 1336253731 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FEREDAY | ||||||||
| FirstName: | RUTH | ||||||||
| MiddleName: | ELAINE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | RR 1 BOX 363 | ||||||||
| Address2: | |||||||||
| City: | KIOWA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745539502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809272334 | ||||||||
| FaxNumber: | 5809279941 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 W OHIO AVE | ||||||||
| Address2: | |||||||||
| City: | COALGATE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745382827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809272334 | ||||||||
| FaxNumber: | 5809279941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 950 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100089380A | 05 | OK | MEDICAID | 950 | 01 | OK | P.A. LIC NUMBER | OTHER |